Download Hip Pain_NOF

Adult Emergency Nurse Protocol
20XX
HIP PAIN (Suspected # NOF)
Aim:
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Early identification and treatment of life threatening causes of hip pain – suspected fractured Neck of Femur (NOF), escalation
of care for patients at risk.
Early initiation of treatment / clinical care and symptom management within benchmark time.
Assessment Criteria: On assessment the patient should have one or more of the following signs / symptoms:
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Hip pain post mechanical fall
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Decreased mobility
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Rotation of the leg on the injured side
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Shortening of the leg on the injured
side
Escalation Criteria: Immediate life-threatening presentations that require escalation and referral to a Senior Medical Officer
(SMO):
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Trauma Call Criteria*
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Syncope / Collapse
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Neurovascular compromise
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Suspected shaft of femur fracture
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Anticoagulant therapy
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Multiple system injuries
Primary Survey:
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Airway: patency
Circulation: perfusion, BP, heart rate, temperature
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Breathing: resp rate, accessory muscle use, air entry, SpO2.
Disability: GCS, pupils, limb strength
Notify CNUM and SMO if any of the following red flags is identified from Primary Survey and Between the Flags criteria 1
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Airway – at risk
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Breathing – respiratory distress
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Circulation – shock / altered perfusion
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Partial / full obstruction
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RR < 5 or >30 /min
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HR < 40bpm or > 140bpm
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SpO2 < 90%
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BP < 90mmHg or > 200 mmHg
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Postural drop > 20mmHg
Capillary return > 2 sec
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Disability – decreased LOC
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Exposure
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GCS ≤ 14 or a fall in GCS by 2 points
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Temperature <35.5°C or >38.5°C
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BGL < 3mmol/L or > 20mmol/L
History:
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Presenting complaint
Allergies
Medications: Anticoagulant Therapy, Anti-hypertensives, Diabetic meds, Analgesics, Inhalers, Chemotherapy, Non-prescription
meds, and any recent change to medications
Past medical past surgical history relevant
Last ate / drank & last menstrual period (LMP)
Events and environment leading to presentation
Pain Assessment / Score: PQRST (Palliating/ provoking factors, Quality, Region/radiation, Severity, Time onset)
Associated signs / symptoms: hip / pelvic pain, nature of pain / radiation,
History: history of falls, collapse or cardiac arrhythmias
Systems Assessment:2-4
Focused hip and lower limb assessment:
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Inspection: Bruises, scars, lacerations, deformities, swelling, symmetry of the pelvis and lower limb (rotation, shortening). If
patient is freely mobilising, assess patient stance, gait and walk for symmetry and heal-strike. Observe for C-sign.5
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Palpate: Palpate for crepitus, pulses and assess for neurovascular compromise.
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Range of movement (stop if pain occurs): straight leg raise and flexion/extension.
Explore mechanism of injury and events leading up to injury to guide further patient assessments.
Notify CNUM and Senior Medical Officer (SMO) if any of following red flags is identified from History or Systems
Assessment.
 Hypotension
 Neurovascular compromise
 Asymmetrical pelvis
 Unrelieved pain post analgesia
 Urinary retention
 Dislocation of hip
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Elderly > 65 years
Acute confusion / agitation
Sepsis (CEC Sepsis Pathway)*
Investigations / Diagnostics:
Bedside:
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BGL: If < 3 or > 20mmol/L notify SMO 
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ECG: [as indicated] look for Arrhythmia , AMI 
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Urinalysis / MSU: if urinary symptoms present
Laboratory / Radiology:
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Pathology: Refer to local nurse initiated STOP
FBC, UEC, Coags (if anticoagulant therapy)
Group and Hold (if bleeding suspected or for OT)
Blood Cultures (if Temp ≤35 or ≥38.5°C)
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Radiology: AP Hip / Pelvis X-ray (CXR if fractured)
Nursing Interventions / Management Plan:
Hip Pain (suspected # NOF) – Adult Emergency Nurse Protocol
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Resuscitation / Stabilisation:
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Oxygen therapy & cardiac monitor [as indicated]
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IV Cannulation (consider large bore i.e. 16-18gauge)
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IV Fluids: Sodium Chloride 0.9% 1 litre stat (discuss with
Symptomatic Treatment:
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Antiemetic: as per district standing order
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Analgesia: as per district standing order
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IV Fluids: as per district standing order
SMO)
Supportive Treatment:
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Nil By Mouth (NBM)
Monitor vital signs as clinically indicated
(BP, HR, T, RR, SpO2)
Monitor neurological status GCS as clinically indicated
Monitor pain assessment / score
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Fluid Balance Chart (FBC)
Consider IDC for Female with confirmed fractured NOF or
males with confirmed fractured NOF and signs of urinary
retention
Monitor neurovascular assessment as clinically indicated
(minimum hourly assessments)
Practice Tips / Hints:
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Regular re-assessment of the patient’s pain, vital signs and neurovascular assessment (minimum standards hourly). Escalate
any abnormalities immediately and document the variance, who you escalated to and the treatment plan.
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Position the patient to ensure comfort. Consider ordering a pressure relieving mattress once the patient is admitted.
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The patient must remain NBM until otherwise advised by a SMO. NBM patient will require maintenance fluids while NBM.
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Any patient who presents with decreased mobility must have a mobility assessment completed and documented prior to
discharge home. Consider the patient’s situation and home arrangements are suitable for discharge.
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Ensure admitted or discharge patients have appropriate pain management prior to leaving the ED.
Further Reading / References:
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SESLHD Patient with Acute Condition for Escalation (PACE): Management of the Deteriorating Adult and Maternity Inpatient
SESLHD/PR283. http://www.seslhd.health.nsw.gov.au/Policies_Procedures_Guidelines/Clinical/Other/SESLHDPR283-PACEMgtOfTheDeterioratingAdultMaternityInpatient.pdf.
NSW Department of Health (2011). Clinical Initiatives Nurse in Emergency Departments. Education Program. Resource
manual. Retrieved on the 09/10/2013 from:
http://www.ecinsw.com.au/sites/default/files/field/file/cin_resource_manual_final_0.pdf
Steele, M. T., Stubbs, A. M. (2011). Hip and femur injuries. In J. E. Tintinalli; J. S. Stapczynski; D. M. Cline; O. J. Ma; R. K.
Cydulka; G. D., Meckler (Eds). Tintinalli’s Emergency Medicine: A comprehensive study guide, 7th ed. Retrieved on the
09/10/2013 from: http://www.accessmedicine.com.acs.hcn.com.au/content.aspx?aID=6391677
Thomas Byrd, JW (2007) Evaluation of the Hip: History and Physical Examination. North American Journal of Sports Physical
Therapy. 2(4): 231-240.
Acknowledgements: SESLHD Adult Emergency Nurse Protocols were developed & adapted with permission from:
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Murphy, M (2007) Emergency Department Toolkits. Westmead Hospital, SWAHS
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Hodge, A (2011) Emergency Department, Clinical Pathways. Prince of Wales Hospital SESLHD.
Revision & Approval History
Date
Revision No.
Author and Approval
Hip Pain (suspected # NOF) – Adult Emergency Nurse Protocol SESLHD
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